Thromboembolic complications following a first isolated episode of superficial vein thrombosis: a cross-sectional retrospective study

Current Diagnostic and Therapeutic Challenges in Superficial Venous Thrombosis

Superficial venous thrombosis (SVT) is a fairly common disorder, characterized by the formation of thrombi inside superficial veins, with or without an associated inflammatory reaction. Its evolution is frequently self-limited. However, serious complications may change this clinical course with extension to deep vein thrombosis (DVT) and pulmonary embolism (PE). SVT shares similar risk factors with DVT and is frequently associated with the presence of varicose veins. However, the occurrence of non-varicose veins could conceal risk factors such as malignancies, thrombophilia, or Buerger's disease. While the clinical diagnosis is generally straightforward, additional diagnostic evaluations are often necessary. Duplex ultrasound (DUS) is an invaluable tool that provides the location of SVT, the proximity to the sapheno-femoral junction, and the clot length, all of which influence the decision for optimal management. The treatment of SVT should be symptomatic, pathogenic (limiting the extension of thrombosis), and prognostic (to prevent complications). There are several guidelines that provide recommendations, and despite the need for more consensus and for further studies, the treatment of SVT should be mainly medical, including anticoagulation in specific clinical situations and symptom relief, with invasive treatment in a minority of cases. Initiation, intensity, and length of anticoagulant treatment should be based on the eventual risk of progression to DVT or PE, which can be high, intermediate, or low, based on the location of SVT and the clot length. Our review summarizes the evaluation and proper management of SVT and highlights the importance of a shared decision within the heart team regarding this condition in order to prevent further complications.

Predictive factors of clot propagation in patients with superficial venous thrombosis towards deep venous thrombosis and pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

A subset of patients with superficial venous thrombosis (SVT) experiences clot propagation towards deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The aim of this systematic review is to identify all clinically relevant cross-sectional and prognostic factors for predicting thrombotic complications in patients with SVT.

DESIGN

Systematic review.

DATA SOURCES

PubMed/MEDLINE and Embase were systematically searched until 3 March 2023.

ELIGIBILITY CRITERIA

Original research studies with patients with SVT, DVT and/or PE as the outcome and presenting cross-sectional or prognostic predictive factors.

DATA EXTRACTION AND SYNTHESIS OF RESULTS

The CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling (CHARMS) checklist for prognostic factor studies was used for systematic extraction of study characteristics. Per identified predictive factor, relevant estimates of univariable and multivariable predictor-outcome associations were extracted, such as ORs and HRs. Estimates of association for the most frequently reported predictors were summarised in forest plots, and meta-analyses with heterogeneity were presented. The Quality in Prognosis Studies (QUIPS) tool was used for risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for assessing the certainty of evidence.

RESULTS

Twenty-two studies were included (n=10 111 patients). The most reported predictive factors were high age, male sex, history of venous thromboembolism (VTE), absence of varicose veins and cancer. Pooled effect estimates were heterogenous and ranged from OR 3.12 (95% CI 1.75 to 5.59) for the cross-sectional predictor cancer to OR 0.92 (95% CI 0.56 to 1.53) for the prognostic predictor high age. The level of evidence was rated very low to low. Most studies were scored high or moderate risk of bias.

CONCLUSIONS

Although the pooled estimates of the predictors high age, male sex, history of VTE, cancer and absence of varicose veins showed predictive potential in isolation, variability in study designs, lack of multivariable adjustment and high risk of bias prevent firm conclusions. High-quality, multivariable studies are necessary to be able to identify individual SVT risk profiles.

PROSPERO REGISTRATION NUMBER

CRD42021262819.

Risk of recurrent thromboembolic events according to treatment duration in patients with superficial vein thrombosis treated with intermediate dose of tinzaparin

OBJECTIVES

To evaluate the risk of symptomatic venous thromboembolism (VTE) recurrence at 3 months in relation to treatment duration, according to baseline risk factor profiles, in patients with superficial vein thrombosis (SVT) treated with intermediate dose of tinzaparin.

METHODS

We performed a pooled analysis on individual data from two prospective studies designed to assess the efficacy and safety of tinzaparin in intermediate dose (131 IU/kg) in patients with SVT. Treatment duration was at the treating physician's discretion. All patients were followed up for at least 3 months.

RESULTS

A total of 956 patients (65% female, mean age 58.7 ± 13.7 years) were included. The median treatment duration was 30 days (range, 3-200 days). History of deep vein thrombosis (DVT), location of SVT above the knee, and palpable induration were the only independent factors associated with prolonged treatment duration. During follow-up, 95.9% of patients were event free. Outcomes-related adverse events occurred in 39 (4.1%) patients and their median duration of treatment was 33 days (range, 7-200 days). Recurrent VTE events occurred in 33 patients, including 22 cases of SVT recurrence, 8 cases of DVT, and 1 case of pulmonary embolism. The median time to the event was 29 (6-113) days. Recurrent thromboembolic events were not related to treatment duration as occurred in 17 patients (51.5%) treated up to 30 days and in 16 patients (48.8%) received prolong treatment (p = .46). Length of thrombus at the index event was significantly associated with higher risk for VTE recurrence.

CONCLUSIONS

Intermediate dose of tinzaparin for 30 days is an effective and safe treatment for SVT. The risk of recurrent VTE events may be higher in patients with greater amount of thrombus at index event.

Urgent surgery versus anticoagulation for treatment of superficial vein thrombosis in patients with varicose veins

Summary: Background: We performed a prospective observational study to compare the results of surgery and anticoagulation in patients with superficial vein thrombosis (SVT). Patients and methods: A total of 190 patients (195 limbs) with varicose veins and SVT were included and treated by anticoagulation or by surgery. Patients were followed-up during 6 months. The primary outcome for treatment efficacy was the composite rate of SVT extension/recurrence; deep vein thrombosis (DVT) or symptomatic pulmonary embolism (PE). The primary outcome for safety was the rate of wound complications and rate of bleedings. Results: Surgery was performed in 85 (44.7%) patients and 105 patients (5 with bilateral SVT) were treated conservatively. In the whole study cohort the primary outcome for treatment efficacy was registered in 15 (7.6%) cases: 9/85 (10.5%) in surgical group and 6/110 (5.4%) in anticoagulation group. Nine patients treated with surgery were diagnosed with postoperative DVT. In anticoagulation group SVT extension occurred in 3 limbs; SVT recurrence in 2 and DVT in one. There were no cases of PE or death during the follow-up. Time-to-event analysis demonstrated no significant difference between groups (HR 0.48; 95% CI 0.17–1.34). The total length of the thrombus was associated with primary efficacy outcome in surgical group (HR 1.07; 95% CI 1.02–1.11); and duration of anticoagulation (HR 0.91 per day; 95% CI 0.83–0.99) and value of Caprini score (HR 1.86; 95% CI 1.1–3.14) in anticoagulation group. Six (7%) wound complications were registered after surgery and 6 (5.71%) bleedings during anticoagulation. Conclusions: Urgent surgery is not associated with reduction of venous thromboembolism compared to anticoagulation in treatment of patients with SVT and varicose veins during 6-months follow-up. However, in patients with isolated thrombosis of varicose tributaries or with limited involvement of the saphenous trunk surgery is relatively safe.

Prognostic Significance of Concomitant Superficial Vein Thrombosis in Patients with Deep Vein Thrombosis of the Lower Limbs

BACKGROUND

 The prognostic significance of concomitant superficial vein thrombosis (SVT) in patients with lower-limb deep vein thrombosis (DVT) has not been consistently evaluated.

METHODS

 We used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the rates of subsequent pulmonary embolism (PE), recurrent DVT, major bleeding or death in patients with lower-limb DVT, according to the presence or absence of concomitant SVT.

RESULTS

 From March 2015 to May 2020, there were 8,743 patients with lower-limb DVT. Of these, 745 (8.5%) had concomitant SVT. Most patients (97.4% in both subgroups) received anticoagulant therapy (median duration: 138 vs. 147 days). During follow-up (median: 193 vs. 210 days), 156 (1.8%) patients developed subsequent PE, 336 (3.8%) had recurrent DVT, 201 (2.3%) had major bleeding and 844 (9.7%) died. Patients with concomitant SVT had a higher rate of subsequent PE (rate ratio [RR]: 2.11; 95% confidence interval [95%CI]: 1.33-3.24) than those with isolated DVT, with no significant differences in the rates of recurrent DVT (RR: 0.80; 95%CI: 0.50-1.21), major bleeding (RR: 0.77; 95%CI: 0.41-1.33) or death (RR: 0.81; 95%CI: 0.61-1.06). On multivariable analysis, patients with DVT and SVT concomitantly were at increased risk of subsequent PE during anticoagulation (adjusted hazard ratio [HR]: 2.23; 95%CI: 1.22-4.05) and also during the entire follow-up period (adjusted HR: 2.33; 95%CI: 1.49-3.66).

CONCLUSION

 Patients with lower-limb DVT and SVT concomitantly are at increased risk of developing PE. Further studies are needed to externally validate our findings and to determine if these patients could benefit from a different management strategy.

Treatment of superficial vein thrombosis with intermediate dose of tinzaparin: A real word cohort study - The SeVEN EXTension study

BACKGROUND

To assess the treatment of superficial vein thrombosis (SVT) with intermediate dose of tinzaparin in a setting of real world practice.

METHODS

Prospective observational study of consecutive patients treated by vascular physicians in the private sector with tinzaparin (131 IU/Kg) once daily. Treatment duration was at the treating physician's discretion. The outcomes of the study were symptomatic venous thromboembolism, extension of thrombus and bleeding complications.

RESULTS

660 patients were included and followed up for at least 3 months. Median duration of treatment was 30 days (14-120). History of prior deep vein thrombosis (HR 2.77; 95% CI= 1.18-6.49; p = 0.018) and current SVT above the knee (HR1.84; 95% CI = 1.33-3.53; p = 0.0002) were associated with prolonged treatment duration. Primary efficacy outcomes occurred in 20 (3%) patients. The median time to the event was 24 (6-92) days and was not related to treatment duration.

CONCLUSIONS

Tinzaparin at intermediate dose is an effective and safe treatment for SVT.

Extended-Duration Treatment of Superficial Vein Thrombosis of the Lower Limbs with Tinzaparin

PURPOSE

To identify risk factors for recurrent thromboembolic events (RTEs) and define the optimum duration of treatment with tinzaparin in patients with superficial vein thrombosis (SVT) of the lower limbs.

MATERIALS AND METHODS

A total of 147 consecutive patients with significant SVT were treated with subcutaneously administered tinzaparin. The composite primary endpoint of the study was RTE, deep-vein thrombosis (DVT) and/or pulmonary embolism (PE) at 120 days. Patients were stratified into group A, where patients received a variable dose of tinzaparin for up to 60 days (n=98), and a subsequent group B-ext, where patients received a standardized intermediate dose of tinzaparin (n=49) for 90 days.

RESULTS

RTEs occurred in 15/147 patients (10.2%), including recurrent SVT (n=10), DVT (n=4) and fatal PE (n=1). RTEs were less frequent in group B-ext (0% vs. 15.3% for group A, P=0.004), a difference that remained significant at the one-year follow-up. Clinically extensive SVT was an independent predictor for RTEs (hazard ratio, 5.94; 95% confidence interval, 2.05-17.23; P=0.001, Cox regression). Predictors or DVT or PE in group A included clinically extensive SVT (P=0.004), absence of local pain (P=0.023) and the ultrasound findings of superficial axial vein thrombosis (any, P=0.006 or isolated, P=0.036) and multiple thrombosed superficial venous sites (P<0.001).

CONCLUSION

An extended three-month regimen of tinzaparin in patients with SVT of the lower limbs is more effective than a shorter course and may be desirable in patients with risk factors.

Medical management of acute superficial vein thrombosis of the saphenous vein

OBJECTIVE

Acute superficial vein thrombosis (SVT) of the axial veins, such as the great saphenous vein (GSV), is a common clinical condition that carries with it significant risk of propagation of thrombus, recurrence, and, most concerning, subsequent venous thromboembolism (VTE). Conservative therapy with nonsteroidal anti-inflammatory medication and heat does not prevent extension of thrombus or protect against recurrent or future VTE in patients with extensive SVT (thrombotic segment of at least 5 cm in length). To prevent future thromboembolic events, anticoagulation has become the treatment of choice for extensive acute SVT in the GSV. In spite of this, the dose and duration of anticoagulation in the treatment of SVT vary widely. This review summarizes the evidence from large prospective, randomized clinical trials on the treatment of SVT with anticoagulation (vs placebo or different doses and durations of anticoagulation) with respect to the outcome measures of thrombus extension, SVT recurrence, and future VTE.

METHODS

A systematic search was performed using the MEDLINE database to identify all prospective, randomized controlled trials of treatment with anticoagulation in patients with SVT in the GSV. Six prospective, randomized trials were identified that met the inclusion criteria and were reviewed in detail.

RESULTS

Treatment of acute SVT was most commonly managed in an outpatient setting using either low-molecular-weight heparin (LMWH) in four studies or, alternatively, a factor Xa inhibitor in one large multicenter trial. LMWH was associated with a lower rate of thrombus extension and subsequent recurrence, especially when an intermediate dose (defined as a dose between prophylactic and therapeutic doses) was used for a period of 30 days. The full effect of treatment with LMWH on the risk of subsequent VTE remains unclear, as do the optimal dose and duration of this drug. Prophylactic doses of fondaparinux, a factor Xa inhibitor, were found to be beneficial in reducing the rate of thrombus extension and recurrence as well as in reducing the risk of subsequent VTE both during treatment and after cessation of anticoagulation in the short term.

CONCLUSIONS

These data suggest that treatment of acute SVT of the GSV with anticoagulation, at doses below therapeutic levels, does offer the benefit of decreased risk of thrombus propagation, recurrence, and, at least in one large randomized clinical trial, subsequent VTE. Future studies to refine optimal dose and duration of anticoagulation to lower the rate of subsequent thromboembolic events and SVT recurrence are needed.